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If a large amount of drainage is present, or there is blistering or frail skin around the
knee joint or the lower extremities, discuss with the nurse and decide if notifying the
surgical team is indicated.
Assess patients pain using the visual analogue scale. Ensure that patients are
premedicated with oral/IV pain medication 30-60 minutes prior to treatment.
Cryotherapy is recommended following physical therapy treatment to reduce pain,
discomfort and swelling in the knee joint.
Modalities:
Patients are encouraged to use cryotherapy for 20 minutes before and after their
independent exercise program.
Precautions:
Monitor wound healing and consult with referring MD if signs and symptoms of
excessive bleeding and poor incision integrity are present.
Monitor for signs of DVT, pulmonary embolism (PE), and/or loss of peripheral
nerve integrity. In these cases, notify the MD immediately.
No exercises with weights or resistance.
Avoid torque or twisting forces across the knee joint especially when WB on
involved limb.
Positioning:
A trochanter roll should be used as needed to maintain neutral hip rotation and
promote knee extension.
Total Knee Arthroplasty Protocol
Copyright 2012 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
A towel roll should be placed at the ankle to promote knee extension when patients
are supine in bed.
Nothing should be placed behind the operative knee, to promote maximal knee
extension and prevent knee flexion contracture.
Neuromuscular electrical stimulation (NMES) for quads if poor quad contraction is present.
NMES parameters to be set based on goal of exercise/activity. See neuromuscular electrical
stimulation procedural standard of care for specific details.)
Gait training to improve function and quality of involved limb performance during
swing through and stance phase. Patients are encouraged to wean off their assistive
device at the latest by the end of second week from surgery.
Postural cues/ reeducation during all functional activities as indicated.
Weeks 4-6
Continue above exercises
Continue patella femoral and tibial femoral joint mobilization as indicated.
Continue NMES of quads if poor muscular performance of quad is present. May
progress NMES use from isometric quad activity to isotonic and functional activity
Front and lateral step up and step down.
1/4 front lunge.
Use sit to stand and chair exercises to increase knee flexion during functional tasks.
Continue stationary bicycle for ROM
Begin pool program if incision is completely healed
*Note: Exercises with resistance may be initiated as tolerated for operative extremity after
goals for the first phase have been met, and the patient has met criteria for progression to the
next phase.
Modalities:
Cryotherapy 1-3x/day for swelling and pain management.
Other modalities at the discretion of the therapist based on clinical findings (Please
see Department of Rehabilitation Services Modality specific procedures).
Precautions:
WBAT with assistive device as needed to minimize compensatory gait. Patient may
be encouraged to use a straight cane within one week of surgery if he/she is WBAT
to FWB. Patients may be weaned from assistive device by 2 weeks if they did not
use an assistive device preoperatively and post-operative muscle performance is
adequate for weight acceptance.
Monitor wound healing and consult with referring MD if signs and symptoms of
infection are present.
Monitor for increased edema and continue with cryotherapy as needed.
Criteria for progression to the next phase:
AROM 0-110
Good voluntary quadriceps control
Therapeutic Exercises:
Continue exercises listed in Phase II with progression including resistance and
repetitions. It is recommended to assess hip/knee and trunk stability at this time and
provide patients with open/closed chain activities that are appropriate for each
patients individual needs.
Continue patella femoral and tibial femoral joint mobilization as indicated.
Initiate endurance program, walking and/or pool.
Initiate and progress age-appropriate balance and proprioception exercises.
Discontinue NMES of quads when appropriate quad activity is present.
Criteria for progression to next phase:
AROM without pain, or plateaued AROM based on preoperative ROM status.
4+/5 muscular performance based on MMT of all lower extremity musculature.
Minimal to no pain or swelling.
Phase IV Advanced strengthening and higher level function stage (week 12-16):
Goals:
Return to appropriate recreational sports / activities as indicated
Enhance strength, endurance and proprioception as needed for activities of daily
living and recreational activities
Therapeutic Exercises:
Continue previous exercises with progression of resistance and repetitions.
Increased duration of endurance activities.
Initiate return to specific recreational activity: golf, doubles tennis, progressive
walking or biking program.
Authors:
Roya Ghazinouri, PT
Amy Rubin, PT
6/2007
Reviewers:
Carolyn Beagan, PT
Janice McInnes, PT
John Wright, MD
Reg B. Wilcox III, PT
Updated by:
Wesley Congdon, PT
1/2012
Reviewed by:
Carolyn Beagan, PT
Roya Ghazinouri, PT